Sorting Out a Medical Mess

MEDICAL EDUCATION is in a mess. At under graduate level, students waste time studying biology and chemistry have which most of them already done at school.

Their course is heavily dominated by the learning of facts - many of which will be out of date within a few years. At the same time, there is concern that they are not acquiring enough clinical skills - even the Irish Medical Council's education committee says in a discussion document: "Undergraduate medical students receive considerably less practical experience than previously."

In a recent lecture, the Minister for Health, Michael Noonan, commented that the average layperson would be quite surprised at the "limited mastery" of certain clinical skills which medical graduates had acquired.

These inadequately prepared medical graduates then go on to a compulsory one year hospital internship, where they endure what the Medical Council's document describes as "onerous duty rosters, excessive overtime, inadequate supervision ... arranging of beds, portering duties and lack of a specific educational programme".

The Irish Medical Organisation puts it more bluntly. "It is supposed to be a form of apprenticeship, a year in which the graduate gets additional training and supervised experience. Indeed the law states that they should only work under super vision," says Dr Doiminic O Brannagain, chairman of the junior doctors committee of the IMO.

"In practice they are gofers, they race along corridors looking for Xrays, digging up files - they are treated as glorified secretaries in some cases. On the other hand they are regularly landed with far more responsibility than they are trained for. You find them left covering casualty with no senior doctor present and working 75 to 85 hours per week - and in some cases 130 to 140 hours."

"They're the work horses of the hospital system," a medical academic comments. "If patients only knew how inexperienced are the doctors who sometimes treat them." The interns, who are supposed to be still in training, in fact get no classes or educational sessions at all.

It is against this background that the Medical Council set up two working parties last summer - one to look at undergraduate medical training and the other to examine the structure of the intern year. Deans of the five medical faculties and other interested parties were involved. Next week, the council issuing a statement with some of its recommendations.

"Radical reform is required of the content and methods of education," one of the word party documents states. One concern is that the six year programme is too long. In Britain and most other EU states, it is a five year programme, and EU directives on mutual recognition of qualifications has focused attention on this.

The document suggests reducing degree courses to five years by omitting the traditional premed year - which has effectively involved medical students doing first year science.

The working party on undergraduate training pointed to a "factual overload" in the degree course and criticised the present "heavily didactic courses based on (faculty) departmental structures".

The Medical Council's recommendations include the changing of medical school curricula from a facts driven approach to a problem solving one more "self learning"; and more progressive assessment and project work rather than the present rigid written exams. It says a core curriculum should be devised to cover basic medical training and there should then be elective modules.

Rather than stuffing the students fell of facts which could soon be redundant, this approach suggests they be equipped with the skills required to adapt to the constant changes and discoveries of modern medicine.

THE REPORT IS also likely to include recommendations that there be more emphasis on communications skills. There has been some concern expressed about the mainly "hospital based clinical training to the exclusion of "community medicine" - such as OP surgeries or public health clinics - but it is not clear that there will be any recommendations in this area.

"A medical student could graduate without having an idea of what a public health nurse does or any experience of care of the elderly," comments one medical critic of the present system.

The intern year working party has been slower to come up with concrete recommendations, but there has been general agreement that the interns are worked too hard, do not get adequate supervision and lack an educational programme. Proposed solutions include timetabled study and learning periods, properly structured training and the attachment of interns to qualified doctors in a type of apprenticeship.

"You don't put a university law graduate straight into the Four Courts and tell him to prosecute a case," one doctor says, "but we roster raw medical graduates in hospitals."

The example of professional legal training or of the higher diploma in education, with its combination of training and teaching, are quoted as possible role models.

Of course, this has staffing implications for hospitals, which at the moment rely heavily on the 300 fresh young interns who arrive each year. This staffing problem was also cited in opposition to university based training of nurses.

WHAT HAPPENS to the newly fledged doctors after the intern year is in even more of a mess - so much so that an estimated one in every two of them now emigrates.

To get almost anywhere in medicine the newly qualified doctor needs to undertake further postgraduate training. This mainly involves studying and sitting further examinations set by bodies such as the Royal College of Physicians or the Royal College of Surgeons. While pursuing this route, the young doctors compete for a series of six month or one year junior hospital doctor positions.

"The trouble with postgraduate, training in Ireland is that it is not structured, there is no defined beginning or end to it," Dr O Brannigain says. "You study, you sit exams, you do all of this while working maybe over 100 hours per week. It depends entirely on the individual. It can take 14 to 15 years to qualify as a specialist in some areas.

However, this is not training as most other professions understand it. In most cases, O Brannagain says, "there are no lectures, no teaching, no supervision by specialists in the area." The junior doctor struggles along and tries to work out for her or himself how to prepare for the professional exams.

The Minister for Health appears to agree with him. "The continued provision of the bulk of hospital care by doctors in training cannot continue," Mr Noonan declared in the Doolin Memorial Lecture, which he delivered three months ago.

"Postgraduate and specialist training needs to be made more formal and structured," he said, "with stronger emphasis on monitoring competence than merely measuring experience. Training programmes should explicitly lay out the clinical competencies which doctors should have acquired at each stage."

Some specialisations, such as surgery and psychiatry, are much better organised, but most are unstructured.

IN OTHER EU states, according to the IMO, there are clearly structured and defined five to eight year postgraduate training schemes with continuous assessment on a three to six monthly basis; the IMO considers such continuous assessment of performance a better means of ensuring high standards than the exam system in operation here.

The IMO is re negotiating the junior hospital doctors contract with the Department of Health, and it wants the provision of formal training included as part of the contract and junior doctors to have training periods included in their roster.

The impossibility of seeing their way through the largely unstructured maze of postgraduate training in Ireland and the insecurity of the six and 12 month contract's - at junior level there is nothing else available - is driving about 50 per cent of young Irish doctors abroad. "I know of no other profession in Ireland where the next generation go abroad so early and spend so much of their careers there," said the Minister in his Doolin lecture. "Is it perhaps a vote of no confidence in our own training system?"

One young doctor explained to E&L why he had opted to do his postgraduate training in London. "I have got a five year contract in London. I will spend the first six months in a local district hospital, then I go for six months to a big training hospital in London. I will work in several different hospitals and different situations, but it is all covered by the one five year contract.

"My career path is also mapped out, with a guarantee that I advance from house officer to registrar and senior registrar - provided my assessments are positive - over the five year period. If I stayed in Ireland, I would have to pursue a new contract every six or 12 months, I'd have no job security, no clear career path, no proper training and the prospect of endless years' sitting exams and still getting nowhere."